NCC230415_FRO Submitted_20230214

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name AMC Mass Grading - Phase 1 (Clearing & Grubbing)
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Hendrick Auto Plaza NW 35.355-80.702
Highway/Street Latltude(decimal degrees) Longitude (decimal degrees)
3. Approximate date land -disturbing activity will commence: 02/01 /2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 88.50
6. Amount of fee enclosed: $ 8900.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Marshall Carlson E-mail Address [e-mail]
Phone: Office # 704-455-3400 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HSREI, LLC / HGREI LLC 704-455-3400
Name Phone: Office # Mobile #
4400 Papa Joe Hendrick Blvd 4400 Papa Joe Hendrick Blvd
Current Mailing Address Current Street Address
Charlotte NC 28262 Charlotte NC 28262
City State Zip City State Zip
10. Deed Book No. 15314 Page No. 163 Provide a copy of the most current deed.
Deed Book No. 5663 Page No. 062, 066
Plat Book No. 0084 Page No. 082

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
HSREI, LLC
Company Name
4400 Papa Joe Hendrick Blvd
Current Mailing Address
Charlotte NC 28262
[e-mail]
E-mail Address
4400 Papa Joe Hendrick Blvd
Current Street Address
Charlotte NC 28262
City State Zip City State Zip
Phone: Office # 704-455-3400 Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Marshall Carlson
Name of Registered Agent
4400 Papa Joe Hendrick Blvd
Current Mailing Address
Charlotte, NC 28262
City State Zip
[e-mail]
E-mail Address
4400 Papa Joe Hendrick Blvd
Current Street Address
Charlotte, NC 28262
City
Phone: Office # 704-455-3400 Mobile #
State Zip
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Marshall Carlson
Vice President & Secretary
Type p 'nt n me Title or Authority
l7i 1 2.
Signature Date
I, , a Notary Public of the County of
State of North Carolina, hereby certify that 4 r U,ty%��A ) CCA' SD" appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 1 day of DfCC�nbCK , 20 �D
11NNQ 1ellA0�,'
9 � Notary
P NQT4,
MY - My commission expires 1
COMM'& M EXPIRES
to ^ ��
�`Y

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Name
Phone: Office # Mobile #
5401 E. Independence Blvd
160 Mine Lake Ct
Current Mailing Address
Current Street Address
Charlotte NC
28212
Raleigh NC 27615
City State
Zip
City State Zip
5452
360
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.